Sonographic diagnosis of fetal cardiac rhabdomyomas in two successive pregnancies in a woman with tuberous sclerosis.

Rhabdomyoma is the most common prenatally diagnosed cardiac tumor. We present two cases of fetal cardiac rhabdomyoma. In each case, fetal ultrasound assessment revealed the intracardiac tumors that were confirmed on postnatal imaging. The mother and her previous child were examined for the markers of tuberous sclerosis and diagnosis of tuberous sclerosis was confirmed. Two years later, cardiac rhabdomyomas were again diagnosed in her subsequent pregnancy. In the postpartum period, total regression of the tumors occurred in both cases.

Diagnostic accuracy of real-time 3D sonography in the diagnosis of congenital Mullerian anomalies in high-risk patients with respect to the phase of the menstrual cycle.

PURPOSE: To compare the diagnostic accuracy of 2-dimensional sonography (2DUS) and real-time 3-dimensional sonography (3DUS) in the diagnosis of congenital mullerian defects (CMD) with respect to the phase of the menstrual endometrium. METHOD: The accuracy of sonography was examined on 108 women by 2 gynecologists during the 1st 5 days after cessation of menstrual flow and then re-examined at the cycle days 20-24. Entrance criteria for the patients enrolled in the study were as follows: women who were referred to our center with a suspected Mullerian anomaly at hysterosalpingography, and women who were suspected to have a uterine anomaly at our hospital during infertility, dysmenorrhea, and recurrent abortion workup. First, 1 of the gynecologists performed the 2DUS, and afterwards the 2nd gynecologist performed the real-time 3DUS. Results from both examiners were compared and correlated with the definitive diagnosis obtained by MRI, laparoscopy, or hysteroscopy. The sensitivity and specificity values of 2DUS and real-time 3DUS for the diagnosis of CMD were calculated at follicular and luteal phases. RESULT: Among the 108 cases suspected to have CMD, the sensitivity and specificity values of real-time 3DUS were significantly higher in the follicular sensitivity, 94.7%, specificity, 75.0%, and luteal phases (sensitivity, 100%, specificity, 93.7%) when compared with 2DUS values (sensitivity of 30.2% and specificity of 78.1% in the follicular phase and sensitivity of 42.1% and specificity of 81.2% in the luteal phase). CONCLUSION: Real-time 3DUS is an accurate method that can be used for the diagnosis of congenital mullerian defects.

Reduction in caesarean delivery with fetal heart rate monitoring and intermittent pulse oximetry after induction of labour with misoprostol.

OBJECTIVE: To integrate intermittent fetal pulse oximetry (FPO) to intrapartum fetal assessment and reduce the rate of caesarean sections. METHODS: A randomised controlled trial using 37 weeks as a restriction point was conducted in 230 women induced with misoprostol. One hundred-fourteen were assessed with intermittent FPO plus fetal heart rate (FHR) monitoring (study group) and 116 were assessed with FHR monitoring alone (control group). The primary outcome measure was caesarean delivery rates. Secondary outcome measures included induction to delivery interval, number of emergency caesarean deliveries performed for fetal non-reassuring FHR patterns and neonatal outcomes. RESULTS: There was a reduction both in the overall caesarean deliveries (study n = 18, (15.7%); vs. control n = 31 (26.7%); p = 0.04), and the rate of caesarean deliveries performed for non-reassuring fetal status in the study group (study n = 11, (9.6%); vs. control n = 23 (19.8%); p = 0.03). Induction to delivery interval was similar in between the groups (759 +/- 481 min in group 1; vs. 735 +/- 453 min in group 2 respectively; p = 0.69). CONCLUSION: Intermittent FPO in misoprostol induced deliveries decreases both total caesarean rate and the caesarean rate due to non-reassuring FHR patterns.

Comparative efficacy and safety of vaginal misoprostol versus dinoprostone vaginal insert in labor induction at term: a randomized trial.

OBJECTIVE: To compare efficacy and safety of vaginal misoprostol (PGE(1) analog) with dinoprostone (PGE(2) analog) vaginal insert for labor induction in term pregnancies. STUDY DESIGN: A total of 112 women with singleton pregnancies of > or =37 weeks of gestation, and low Bishop scores underwent labor induction. The subjects were randomized to receive either 50 mug misoprostol intravaginally every 4 h to a maximum of five doses or a 10 mg dinoprostone vaginal insert for a maximum of 12 h. Time interval from induction to vaginal delivery, vaginal delivery rates within 12 and 24 h, requirement of oxytocin augmentation, incidence of tachysystole and uterine hyperstimulation, mode of delivery, rate of cesarean section due to fetal distress and neonatal outcome were outcome measures. Student's t test, Chi square test, Fischer's exact test were used for statistical analysis. RESULTS: Time interval from induction to vaginal delivery was found to be significantly shorter in misoprostol group when compared to dinoprostone subjects (680 +/- 329 min vs. 1070 +/- 435 min, P < 0.001). Vaginal delivery rates within 12 h were found to be significantly higher with misoprostol induction [n = 37 (66%) vs. n = 25 (44.6%); P = 0.02], whereas vaginal delivery rates in 24 h did not differ significantly between groups [n = 41 (73.2%) vs. n = 36 (64.2%); P = 0.3]. More subjects required oxytocin augmentation in dinoprostone group [n = 35 (62.5%) vs. n = 20 (35.7%), P = 0.005] and cardiotocography tracings revealed early decelerations occurring more frequently with misoprostol induction (10.7 vs. 0%, P = 0.03). Tachysystole and uterine hyperstimulation, mode of delivery, rate of cesarean sections due to fetal distress and adverse neonatal outcome were not demonstrated to be significantly different between groups (P = 1, P = 0.5, P = 0.4, P = 0.22, P = 0.5). CONCLUSION: Using vaginal misoprostol is an effective way of labor induction in term pregnant women with unfavorable cervices, since it is associated with a shorter duration of labor induction and higher rates of vaginal delivery within 12 h. Misoprostol and dinoprostone are equally safe, since misoprostol did not result in a rise in maternal and neonatal morbidity, namely, tachysystole, uterine hyperstimulation, cesarean section rates and admission to neonatal intensive care units as reported previously in literature.

The efficacy, cost and patient satisfaction of classic versus office hysteroscopy in cases with suspected intrauterine space occupying lesions with 3-dimension ultrasound and abnormal uterine bleeding.

OBJECTIVE: The aim of this study is to compare the diagnostic efficacy, treatment effectiveness and cost of office hysteroscopy procedure with classic hysteroscopy in women suspected of having an intrauterine space occupying lesion, after being examined for abnormal uterine bleeding. MATERIAL AND METHODS: Among 544 cases admitted to our outpatient clinic due to abnormal uterine bleeding, 123 cases suspected of having an intrauterine space occupying lesion on 3D transvaginal ultrasound were included in the study. Patients were informed about classic and office hysteroscopy and asked to choose one of them. Fifty-seven cases preferred classic hysteroscopy and 66 cases preferred office hysteroscopy. The Visual analog scale was used to measure pain in office hysteroscopy cases while the Likert scale was used for patient satisfaction and cost was calculated in Turkish Lira. RESULTS: According to the histopathological examination, 65.9% of the cases (n=81) were diagnosed as polyp and 7.3% of the cases (n=9) were diagnosed as submucous leiomyoma. Mean operation time was 11±5.6 min. for office hysteroscopy and 42.6±18.4 min. for classic hysteroscopy (p<0.001). The level of pain before the operation was 0.3±0.1 (0-1), during the operation 2.8±2.5 (0-10) and after the operation 1.5±1.6 (0-8) in Office hysteroscopy cases. Among the Office hysteroscopy cases, 89.3% were very satisfied and 86.3% will advise other patients to have the procedure. Patients were evaluated at sixth month after the procedures and 92.4% of office hysteroscopy group and 96.4% of classic hysteroscopy group were symptom free. At sixth month of the office hysteroscopy procedure 83.3% of the cases were satisfied with the procedure and 81.8% would advice other patients to have the procedure. The mean cost of classic hysteroscopy was 3.6 times higher than the office procedure. CONCLUSION: Office hysteroscopy is a safe and satisfactory procedure for the patient and provides a fast "see and treat" option at a low cost as an out patient procedure without need for general anesthesia. It should be utilized as a first line diagnosis and treatment option.

Fetal pulse oximetry: correlation with intrapartum fetal heart rate patterns and neonatal outcome.

AIM: To determine how fetal pulse oximetry behaves in various cardiotocographic (CTG) tracings and correlates with neonatal outcome. PATIENTS AND METHODS: Pregnant women undergoing active labor with singleton pregnancies of 32-42 weeks were enrolled. CTG recordings were reassuring or nonreassuring (namely variable or persisting late decelerations). Pulse oximetry values during labor and changing throughout deceleration and recovery phases, duration and frequency of pulse oximetry recordings <30%, and neonatal outcome were determined. One-way anova, Tukey test, chi(2)-test and multiple logistic regression model were used for statistical analysis where appropriate. RESULTS: A total of 156 pregnant subjects were divided into three groups: reassuring fetal heart rate (FHR) patterns (group 1, n=78 [50%]), late decelerations (group 2, n=16 [10.3%]) and variable decelerations (group 3, n=62 [39.7%]). The initial and final pulse oximetry readings, pulse values in first stage of labor, the duration and the frequency of pulse oximetry recordings <30% were significantly different between groups (P<0.001, P<0.001, P<0.001, P=0.001, P<0.001). Fetal acidosis was significantly more frequent with late decelerations (23.1%, P=0.004). A multiple logistic regression model demonstrated that the initial pulse oximetry value during active labor was the most predictive variable of neonatal well-being (P<0.001). CONCLUSION: Decreased fetal pulse oximetry values, especially prolonged and recurrent recordings <30% are well-correlated with abnormal FHR patterns, indicating an association with fetal compromise and metabolic acidosis. Going through active labor with a lower initial value of FSpO(2) more frequently leads to an altered FHR pattern and subsequent adverse fetal outcome.

Three-dimensional ultrasonographic diagnosis and hysteroscopic management of a viable cesarean scar ectopic pregnancy.

Implantation of conception material within a cesarean section scar is an extremely rare form of ectopic pregnancy with devastating complications, such as uterine rupture and intractable bleeding. Both 2-D and 3-D transvaginal ultrasonographic devices are used adequately for precise diagnosis, but there is still a lack of consensus concerning management strategies. No therapeutic modality is suggested to be entirely efficacious and safe for preserving uterine integrity. We present here a 29-year-old woman with vaginal bleeding and a gestational sac with a viable embryo of 6 weeks of age that was implanted in a cesarean section scar. Serum beta-hCG levels were 16 792 mIU/mL. Following an unsuccessful treatment course of systemic methotrexate, the patient underwent operative hysteroscopy. Minimally invasive hysteroscopic resection of the ectopic gestational mass without major complication appears to be an alternative therapeutic approach with minimal morbidity and preservation of future fertility.

Doppler examination of uteroplacental circulation in early pregnancy: can it predict adverse outcome?

PURPOSE: To determine whether spectral Doppler measurements obtained from bilateral uterine, arcuate, radial, and spiral arteries in early gestation correlate with adverse pregnancy outcome. METHODS: One hundred five pregnant women underwent transvaginal Doppler sonographic examination of uteroplacental circulation at 6-12 weeks' gestation. Resistance index (RI) and pulsatility index (PI) of bilateral uterine, arcuate, radial, and spiral arteries were measured. Diameters of gestational sac (GS) and yolk sac, crown-rump length (CRL), GS-CRL difference, and GS/CRL ratio were also recorded. Correlation was made with pregnancy outcome. RESULTS: Sixteen women developed adverse pregnancy outcome. In these women, right uterine artery PI and RI were significantly higher than in women with normal obstetrical outcome. Spiral artery PI and RI values were also higher, but the difference was not statistically significant. GS-CRL difference, GS/CRL ratio, and yolk sac diameters were significantly lower in this group. CONCLUSION: Transvaginal Doppler examination can detect hemodynamic changes in uteroplacental circulation associated with subsequent adverse pregnancy outcome.

Randomized comparison of 3 misoprostol protocols for abortion induction at 13-20 weeks of gestation.

OBJECTIVE: To evaluate the induction-to-abortion time of 3 pharmacokinetic-based protocols at 13-20 weeks of gestation. STUDY DESIGN: A randomized trial was conducted on 153 patients. The oral group (n = 51) received 100 microg misoprostol orally every 2 hours, the vaginal group (n = 51) received 200 microg misoprostol vaginally every 4 hours, and the sublingual group (n = 51) received 100 microg misoprostol sublingually every 2 hours. RESULTS: The mean induction-to-delivery time was shorter in the sublingual group (mean, 651 +/- 507) as compared to the vaginal group (mean, 1,056 +/- 634, p = 0.01). The number of patients who delivered within 12 hours was significantly higher in the sublingual group (n = 39, 78%) as compared to the oral (n = 26, 52%) and vaginal (n = 20, 40%) groups (p < 0.001). The numbers of patients who delivered within 24 hours were comparable in the sublingual (n = 47, 94%) and oral (n = 46, 92%) groups but higher than in the vaginal group (n = 39, 78%; p = 0.02). The total misoprostol dose was 543 +/- 422 microg in the sublingual group, 878 +/- 533 microg in the vaginal group and 741 +/- 413 microg in the oral group (p < 0.001). CONCLUSION: A pharmacokinetic-based application of 100 microg of sublingual misoprostol every 4 hours is more effective for induction of second-trimester abortion as compared to 100 microg oral misoprostol every 2 hours and 200 microg vaginal misoprostol every 4 hours.

Misoprostol 50 microg sublingually versus vaginally for labor induction at term: a randomized study.

OBJECTIVE: To compare the efficacy of misoprostol 50 mug vaginally and 50 mug sublingually for labor induction at term. MATERIALS AND METHODS: One hundred and sixty women were randomized to receive misoprostol 50 microg vaginally (n = 80) or 50 microg sublingually misoprostol (n = 80). The doses were given every 4 h (maximum 6 doses). Primary outcome measure was number of cesarean deliveries. Induction to delivery time, delivery within 24 h, the number of misoprostol doses given; the need for oxytocin augmentation, tachysystole and uterine hyperstimulation rates and neonatal outcomes were secondary outcome measures. RESULTS: The mean induction to delivery time was 748 +/- 379 min in the vaginal group and 711 +/- 425 in the sublingual group (p = 0.56). The number of women delivering within 24 h was 73 (91.3%) in the vaginal group and 74 (92.5%) in the sublingual group (p = 0.78). The mean number of misoprostol doses required was significantly higher in the sublingual group (1.9 +/- 1.2) compared with the vaginal group (1.1 +/- 0.4; p < 0.001). More women in the sublingual group experienced tachysystole (n = 14, 17.5%) compared with the vaginal group (n = 3, 3.8%; p = 0.005). Seven cases (8.8%) in the vaginal group and 12 cases in the sublingual group (15%) required emergent cesarean delivery for fetal heart rate abnormalities (p = 0.22). Other neonatal outcomes including umbilical artery pH, Apgar scores and intensive care unit admission were similar in the two groups. CONCLUSION: Sublingual misoprostol is as efficacious as vaginal misoprostol for induction of labor. More frequent tachysystole is observed with misoprostol 50 microg sublingually, but neonatal outcomes are similar.

Pure nongestational choriocarcinoma of ovary.

INTRODUCTION: Primary ovarian choriocarcinoma arising presumably from a germ cell is extremely rare. Besides arising gestationally or nongestationally, it may be pure or mixed with other germ cell tumors like immature teratoma, dysgerminoma, polyembryoma. CASE REPORT AND DISCUSSION: We present a case of a 22-year-old woman diagnosed with pure nongestational choriocarcinoma of the ovary with a review of the literature and discussion of its origin.